Indiana became the second state in the U.S. to install work requirements for certain Medicaid beneficiaries, joining Kentucky as the only states to do so.

Health and Human Services Secretary Alex Azar announced approval of a federal waiver to allow Indiana to establish work requirements. The waiver is part of a three-year extension of the state’s Medicaid expansion.

“Healthy, fulfilling lives not just require health coverage or healthcare but a sense of purpose often obtained through work,” said Azar, who was sworn in as secretary Monday.

Starting in 2019, the state will require able-bodied and working-age Medicaid beneficiaries to go to school, find a job, or participate in other qualifying events such as volunteering or job skills training for 20 hours a week.

Some beneficiaries, including those who are medically frail, students or pregnant, will be exempt from the requirements, said Indiana Family and Social Services Administration Director Jennifer Walthall at the press conference.

She estimates that of the state's 400,000 Medicaid recipients, 130,000 of them would qualify under the new work requirements.

Walthall said the goal is to ensure that nobody loses coverage if they don’t satisfy the work requirements.

However, 25,000 people in the state lost their Medicaid benefits for six months from 2015 to October 2017 because they weren’t able to pay premiums under a program initiated by then Gov. Mike Pence, according to Kaiser Health News. The three-year extension will include premiums.

Azar said the extension of Indiana's Medicaid program includes a new substance abuse component to allow Indiana to expand access to treatment sites.

Indiana and Kentucky are not likely to be the last states to adopt Medicaid work requirements. Azar said 11 states have applied for work requirement waivers.